Health Promotion and Health Literacy: Toward transformative action for non-communicable diseases

A women’s peer group discussion on community health needs in Dodoma, Tanzania. Photo: © Swiss TPH/A. Abdallah 2012

Health promotion and health literacy: from Ottawa Charter to Shanghai Declaration

The Sustainable Development Agenda, and health-related SDG3 give important attention to health promotion as a holistic approach to the prevention of non-communicable diseases (NCDs) by promoting physical, mental and social well-being (Eckermann, 2016; WHO, 2015; WHO¹). The concept was laid out in the Ottawa Charter of 1986 at the first International Conference on Health Promotion in order to develop mandates for achieving the global health strategy of Health for All (WHO¹). Health promotion is: “the process of enabling people and groups to increase control over, and to improve their health and quality of life”, which focuses on ensuring equal opportunities and enabling people to access the resources needed to achieve better health (WHO¹). The concept of health literacy was elaborated in the Shanghai Declaration of 2016, and is defined as “the ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” (WHO²). It focuses on inclusive and equitable access to health information that empowers people to undertake action to improve their own health, as well as the health of their families and communities.  

Strengthening community action and empowerment are central and effective ways for enhancing access to health information and services, enabling people to maintaining good health, and changing health-related culture, social norms and behaviors (Dugani et al., 2017; Kessler and Renggli, 2011). Also, the health promotion approach aims to encourage interactive cooperation with the health care and broader systems such as social, economic, educational, environmental and political structures (WHO, 2015), in line with the multi-sectoral approach of the SDGs.

Social and behavioral risk factors of NCDs and related disabilities

Social, environmental and demographic factors all influence peoples’ means and possibilities and - by extension - their lifestyles and behaviors (see Figure 1). Tobacco use, unhealthy diet, physical inactivity and alcohol over-consumption have been identified by WHO (WHO, 2014^a) as major behavioral factors driving the global rise in NCDs including cardio vascular diseases (CVDs), cancers, diabetes and chronic lung diseases (Dans et al., 2011; SD¹; Wang et al., 2016). Additionally, genetic and epigenetic risk factors increase the complexity of pathways and determinants of NCDs (Lillycrop and Burdge, 2012; Sharp and Reltion, 2017).

Figure 1. Determinants and chronic conditions of NCDs (modified from Dans et al., 2011)

People with NCDs can suffer from a range of chronic symptoms including persistent pain and limited physical capacity as well as sensory, cognitive and mental disorders (Lisy et al., 2016; Richards et al., 2016). In low- and middle-income countries, a lack of planning to address the complex psychosocial, economic and environmental determinants of NCDs, has led to a rapid rise in premature deaths and disabilities (Checkley et al., 2014; Wang et al., 2016). These risk factors are preventable and can be addressed through targeted policy and practice. Therefore, increasing health literacy is important to strengthen knowledge at the national, community and individual levels as part of wider efforts to empower people to make informed choices about their diet, physical activity, alcohol and tobacco consumption and therefore their risks to NCDs.

Increasing global burden of disease: evidence from Tanzania and Tajikistan

The SDGs identify NCDs as a leading cause of 68% of deaths worldwide and both in high, middle and low-income countries (WHO, 2015; Wang et al., 2016). The increasing burden of NCDs is a significant topic in global health and sustainable development (WHO, 2014^a, 2015). Four main NCDs, cardiovascular diseases (CVDs), chronic respiratory diseases, diabetes and cancers, are estimated to cause 80% of NCD-related deaths globally (WHO³). NCD-related disability is estimated at 66.5% of all years lived with disability (YLD) in low- and middle-income countries (WHO, 2011) as a result of social and demographic transformation as well as lifestyle and diet changes (Lisy et al., 2016).

As Figure 2 shows, in Tanzania, NCDs are estimated to account for 30% of total deaths (WHO, 2014^b). CVDs are the leading cause of mortality followed by cancers, diabetes and chronic respiratory diseases. In Tajikistan, NCDs account for 62% of total deaths. The biggest contributor are CVDs estimated at 38% of mortality, followed by cancers, chronic respiratory diseases and diabetes. In Tajikistan, CVDs are the main cause of death determined by unhealthy dietary practices, including high salt and trans fat consumption. Furthermore, obesity is also a key risk factor causing diabetes, cancer and CVDs nationally (WHO⁴).

Figure 2. Proportional mortality rates and NCDs (WHO, 2014^b)

Among the top 10 contributors to NCD-related disability-adjusted life years (DALYs), the top two risk factors in both Tanzania and Tajikistan are malnutrition and air pollution, which contribute to ill-health, disability and early death (IHME, 2016). Specifically, behavioral risk factors contributing to disability and death include alcohol consumption, unhealthy food and tobacco use. The top three chronic conditions in both countries are skin diseases, low back pain and neck pain, and also sensory conditions affecting vision and hearing. Additionally, in both countries, depression, migraine and anxiety disorders are substantial causes of disability. The combination of NCD-related disabilities not only impact the well-being of both populations, but also place a social and economic burden on individuals, households, communities and governments as activity and productivity are reduced (WEF, 2011).  

Addressing health priorities through community participatory health promotion in Tanzania

The Health Promotion and Systems Strengthening Project (HPSS) is being implemented since 2012 in Dodoma Region as a bilateral project funded by the Swiss Agency for Development and Cooperation (SDC). The project has the goal of improving both the supply and demand for quality health services and strengthening health and community development systems, the latter by empowering communities to take action to improve their health. The project built the capacity of government health and community development officers to facilitate community participation, to identify and prioritise health concerns as well as planning, budgeting and applying for council funding. By building those capacities, sustainable means of community action for health have been established in Dodoma Region.

To holistically and sustainably support community participatory action for health, the project strengthened five action areas, in line with the pillars of health promotion defined by the Ottawa Charter in 1986 (WHO¹), namely:

Building public policy

As there was no national health promotion strategy in Tanzania, the project liaised with the Ministry of Health to agree that a regional strategy be developed and piloted in Dodoma. The project established a health promotion strategy technical working group including with regional and district health teams, school health coordinators and NGOs and the resulting regional strategy was used to guide HPSS’s health promotion planning and implementation. The central Ministry was kept informed and subsequently requested HPSS to assist in developing a national health promotion strategy that was modeled on the one piloted in Dodoma Region. The project also provided inputs based on experience in Dodoma to further policy development that included, for example, the 2016 National School Health Strategic Plan 2016-2021 (United Republic of Tanzania, Ministries of Health and Education, 2016).

Creating a supportive environment

In order to establish clear responsibilities among government duty-bearers, the HPSS project negotiated with regional and district authorities to amend the job descriptions of health and community development officers. These set out their duties with regard to community participatory health promotion activities. The project also coached these officers as well as community organizations engaging in health promotion. To support the demand for community-owned water and sanitation initiatives, the project launched a Sanitation Revolving Fund, to ensure a supply of sanitation hardware that was accessible to the poor in rural areas. Peer education and support mechanisms were also established through 700 primary school health clubs.

Development of skills

As engagement from other sectors was also required, all District School Health Coordinators, Health and Community Development Officers in the region were also trained in participatory health promotion techniques by HPSS. To ensure sustainability of health promotion skills and research in the region, the project further capacitated four lecturers at the University of Dodoma and strengthened this institution to launch a new, cross-disciplinary course on health promotion. At the community-level, the project trained Community Health Workers to manufacture and socially market latrine slabs.

Strengthening community actions

The project initiated community dialogue - facilitated by the trained community officers - to discuss and prioritize health concerns in peer groups, as well as to plan action. It also supported communities to apply for council funding for health promotion amenities. To date, over 200 village community-led total sanitation exercises have been completed in 132 villages, improving health literacy on hygiene and sanitation; and the project has supported community, domestic and school water and sanitation actions.

Reorienting health services

By training all Health Officers, Community Development Officers, Council Health Management Teams and Regional Health Management the project reoriented both the health and community development services towards facilitating participatory health promotion approaches together with communities. An outcome of the more holistic, preventive thinking was the rapid, community participatory response to the cholera outbreak response in the winter of 2015.

Voting for community health priority in community meetings in Tanzania. Photo Left: © Swiss TPH/K. Molesworth, 2012; Right: © Swiss TPH/ A. Abdallah, 2012

At the outset of the project the majority of communities in Dodoma region prioritized health issues such as malaria, diarrhoea, eye diseases and skin diseases during their community session and voted to take action to provide safer drinking water and better sanitation. Although many communities raised concerns particularly related to cancers, heart diseases and diabetes, none prioritized these for community action. Given the rapid rise in NCD-related mortality and morbidity in Tanzania, the project has since been working with communities and their government officers to apply these participatory health promotion techniques and better understand NCDs, and the many ways in which they can be prevented and managed in the context of stronger community health systems.  

Increasing health literacy in rural Tajikistan: participatory health planning

In Tajikistan, the SDC-funded Enhancing Primary Health Care Service project works with the Ministry of Health and Social Protection (MoHSP) and focuses on the six rayons of Tursunzoda, Shakhrinav, Vose, Hamadoni, Rudaki and Faizabad. Its objectives include increasing health literacy as well as promoting community participation in health planning for increased accountability and transparency of health care service delivery. The efforts to increase health literacy have focused on wider issues such as entitlements and rights. In addition, specific attention is given to NCDs given the high burden in the country. For example, in collaboration with Save the Children, mass media is used to promote healthy diets and lifestyles, the importance of taking exercise, as well as of using preventive services like blood pressure checks at PHC level. 

A participatory health literacy approach is used and includes the following processes:

Community participation in identifying health needs

Each community has a community health team (CHT) which facilitates community participation in identifying health needs and disseminating information on NCDs such as CVDs and lifestyle-related determinants of health at grassroots level.  

Prioritizing local health needs at a community meeting in Tajikistan. Photo: © Swiss TPH/B. Matthys, 2012

Participatory health planning

CHT representatives bring prioritized community health needs to the annual health planning process which is organized by rural health center staff (family doctors and nurses) and staff from the so-called Healthy Lifestyle Centres. CHT representatives explain the health needs identified from their communities and report back to the community on the health planning meeting. Such a participatory process strengthens community trust in PHC. Further, the process enables joint decision making in setting annual targets, as well as the transfer of knowledge and information on NCDs and the related social and behavioral risk factors to the community.

Implementing health plans

Rural Health Centres are responsible for implementing their annual health plans jointly with the CHT. PHC staff also share their knowledge through health promotion activities and public events related to the identified health priorities.

Monitoring and analysis of the process

As well as being involved in the priority setting and planning process, CHT representatives participate in monitoring and following up the implementation of the health plan thus increasing the accountability for progress to local communities.

At policy level, the Ministry of Health and Social Protection of the Republic of Tajikistan has cumulated these approaches in defining a unified approach for working with communities, as laid out in the National Guideline “Partnership with communities on health issues”, approved by the Order No.153, 9 March 2017. As a result of the health literacy approach, community members have – illustratively - improved knowledge and practice with regards to NCDs, and specifically CVDs. In 2017, over one third (69%) of community members had solid knowledge of CVD risk factors, compared to 54% in 2015. Also, community members are more conscious that they themselves can control and influence their own health. Further, community members give greater attention to considerations of diet such as losing weight, eating less fat and sugar, and more fruits and vegetables, and show increased awareness of the importance of physical exercise for promoting health. The project is continuing to track the translation of knowledge into practices, behavior and the knock-on contributory effect on preventing NCDs and related disabilities. 

Conclusions

The rising burden of NCDs is causing significant negative economic and social impacts, in particular in low- and middle income countries. Amongst other factors, low levels of health literacy, and insufficient knowledge of risk factors and possibilities for change are also contributing to this burden of NCDs. In this article, we have illustrated how participatory interventions to increase health literacy and involve communities in health planning and health promotion can form an important part of the response to NCDs.

Participatory health promotion and health literacy build the capacities of individuals, families and communities to take positive health and lifestyle choices on a day-to-day basis, thus preventing or mitigating the severity of NCDs. Increased health literacy and stronger health promotion capacities at the intersection of community and health care systems offer a promising and solution-oriented approach for addressing the underlying socio-economic and environmental determinants of health. 

References

• Checkley W. et al. (2014) Management of non-communicable disease in low- and middle-income countries, Global Heart, 9(4), 431–443, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4299752/pdf/nihms647522.pdf
• Dans et al. (2011) The rise of chronic non-communicable disease in southeast Asia: time for action, Lancet, 337, 680-9, http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)61506-1.pdf
• Dugani S., Bhutta Z.A. and Kissoon N. (2017) Empowering people for sustainable development: the Ottawa Charter and beyond, Journal of Global Health, 7 (1), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5481890/pdf/jogh-07-010308.pdf
  
• Eckermann L. (2016) Health Promotion principles as a catalyst for translating the SGDs into more transformative action, an editorial paper, Health Promotion International, 31, 253-257, https://academic.oup.com/heapro/article/31/2/253/1751354
• IHME (2016) GBD Country Profiles, Institute for Health Metrics and Evaluation, available to access at: http://www.healthdata.org/results/country-profiles, last accessed on 16 October 2017
• Kessler C. and Renggli V. (2011) Health Promotion: Concepts and Practices, a key issue paper focusing on the relevance for international cooperation, elaborated by the Swiss Centre for International Health (SCIH) of the Swiss Tropical and Public Health Institute (Swiss TPH) in the frame of the 2010/11 Swiss Agency for Development and Cooperation (SDC) Backstopping Mandate. http://www.medicusmundi.ch/de/schwerpunkte/chronische-krankheiten-die-globale-epidemie/gesundheitsfoerderung-und-praevention-1/health-promotion-concepts-and-practices/at_download/file
• Kumar S. and Preetha G. (2012) Health promotion: an effective tool for global health, Indian Journal of Community Medicine, 37 (1), 5-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326808/
• Lillycrop K.A. and Burdge G.C. (2012) Epigenetic mechanisms linking early nutrition to long term health, Best Practice & Research Clinical Endocrinology & Metabolism, 26, 667–676. https://www.ncbi.nlm.nih.gov/pubmed/22980048
• Lisy K., Aromataris E., Moola S., Tufanaru C. and Lockwood C. (2016) Magnitude and scope of non-communicable disease-related disability: a systemic review protocol, JBI Database of Systematic Reviews and Implementation Reports, 14 (10), 112-133. https://www.ncbi.nlm.nih.gov/pubmed/27846122
• United Republic of Tanzania (MoH, 2016) National School Health Strategic Plan 2016-2021, Ministry of Health, Community Development, Gender, Elderly and Children, in collaboration with Ministry of Education Science and Technology

• Richards N.C., Gouda H.N., Durham J., Rampatige R., Rodney A. and Whittaker M. (2016) Disability, noncommunicable disease and health information, Bulletin of the World Health Organization, 94, 230-232. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4773929/
• SD¹, Sustainable Development Goal 3: Ensure healthy lives and promote well-being for all at all ages, available to access at: https://sustainabledevelopment.un.org/sdg3, last accessed on 18 August 2017 
• Sharp G.C. and Relton C. L. (2017) Epigenetics and noncommunicable diseases, Epigenomics, 9(6), 789–791. https://www.futuremedicine.com/doi/full/10.2217/epi-2017-0045
• Wang H, Naghavi M, Allen C, et al. (2016) Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet, 388, 1459–1544. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31012-1/abstract
• WEF (2011) The Global Economic Burden of Non-communicable Diseases, a report by the World Economic Forum and the Harvard School of Public Health, available to access at: http://apps.who.int/medicinedocs/documents/s18806en/s18806en.pdf, last accessed on 17 August 2017
• World Health Organization (WHO, 2008) Regional Strategy for Health Promotion for South-East Asia. India: WHO Regional Office for South-East Asia, available to access at: http://apps.who.int/iris/handle/10665/205837, last accessed on 14 November 2017. http://apps.searo.who.int/PDS_DOCS/B3147.pdf
• WHO (2011)World report on disability, available to access at: http://www.who.int/disabilities/world_report/2011/en/
• WHO (2014^a) Global status report on Non-communicable disease 2014, Geneva: World Health Organization, available to access at: http://www.who.int/nmh/publications/ncd-status-report-2014/en/, last accessed on 17 August 2017
• WHO (2014^b) Non-communicable Diseases Country Profiles 2014, available to access at: http://www.who.int/nmh/countries/en/#T, last accessed on 16 October 2017
• WHO (2015) Health in 2015: from MDGs to SDGs, Geneva, World Health Organization, available to access at: http://apps.who.int/iris/bitstream/10665/200009/1/9789241565110_eng.pdf?ua=1, last accessed on 18 August 2017
• WHO¹, The Ottawa Charter for Health Promotion: First International Conference on Health Promotion, Ottawa, 21 November 1986, available to access at: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/, last accessed on 22 August 2017
• WHO², The mandate for health literacy, available to access at: http://www.who.int/healthpromotion/conferences/9gchp/health-literacy/en/, last accessed on 31 October 2017
• WHO³, Non-communicable diseases, available to access at: http://www.who.int/mediacentre/factsheets/fs355/en/, last accessed on 31 October 2017
• WHO⁴, Tajikistan develops strategy to tackle nutrition, diet and related non-communicable diseases, available to access at: http://www.euro.who.int/en/health-topics/disease-prevention/nutrition/news/news/2012/09/tajikistan-develops-strategy-to-tackle-nutrition,-diet-and-related-noncommunicable-diseases, last accessed on 31 October 2017